Ruminations by a non-academic general surgeon from the heart of the rust belt.

Tuesday, December 4, 2007

Friday night special

The last case of the day Friday was a classic. She was an 80 year old lady who'd been suffering from biliary colic for a number of years who finally decided to have her gallbladder taken out. Preoperative liver function tests were normal, but there was a suggestion of mild intrahepatic biliary dilatation on the CT scan. I repeated the LFT's in a week and, again, they were normal. So we prepared for laproscopic cholecystectomy. The gallbladder was jam pack full of hard stones and it was difficult to get a good grip on the fundus. There were a lot of dense adhesions, but I went slow, teasing away the tissue strand by strand. I identified a thin tubular structure coming out of what appeared to be the distal infundibulum of the gallbladder. I made a nick and inserted my cholangiocatheter. Under fluoroscopy, the dye seemed to flow easily into the duodenum but I couldn't get the proximal ducts to opacify. Based on the cholangiogram, one would have to conclude one was in the common duct. So I pulled out the cholangiocatheter and started to work a bit more on the dissection. There was a giant stone in the infundibulum, which made retraction suboptimal, but I was able to free things up a bit more and I thought I saw another ductal structure posteriorly. This is where the anal sphincter tightens up a bit. With retraction, the stone in the distal infundibulum started to break through the wall and it wasn't clear to me where the cystic duct was at this point. So I opened. I took the gallbladder down and it became apparent that there was a ping pong ball-sized stone lodged 1/2 in the common duct, 1/2 in the distal infundibulum. There was no cystic duct. I cut across the distal gall bladder and popped out the stone, leaving me with a fairly good sized defect in the lateral common duct. I closed the cholangiocather site with a single stitch of 3-0 PDS. Then I closed the common duct transversely around a 14f T-tube. A Jackson-Pratt drain was placed and I got out of Dodge. The intraoperative cholangiogram through the T-tube showed.... normal filling of all the intrahepatic radicles. Currently, she's doing great. LFT's are normal. No bile in the JP. I clamped off the T-tube. Plan for T-tube cholangiogram in 6 weeks.

The lesson in this case was: Trust Your Cholangiogram. Misinterpretation of a cholangiogram is one of the leading causes of severe biliary injury during lap chole. It isn't enough to simply "do the cholangiogram in the standard fashion." Think about what you see. It would have been easy to attribute nonfilling of the right and left ducts to a wide open sphincter of Oddi and just finishing the case. Especially on a Friday night. If the pictures you're receiving on the cholangiogram don't correspond to the mental image you have about what the anatomy is, then further investigation is necessary. You don't want to end up with this.

Have read all of your posts over the past few weeks and really enjoy your writing. As a surgery resident, I particularly enjoy teaching blogs like this one. Keep 'em coming. Excellent case and great teaching points. Thanks.

I'm a first-year x-ray student tasked with a report on laparoscopic cholangiograms...I have been unable to get a lot of information out of the docs and nurses when I've been out at clinical, but would you be able to explain basically what is going on in this procedure? What is being cut away as the Triangle of Calot is being dissected and the Cystic Duct is identified? What are you looking for when fluoro-ing? What is the technical name for the cauterizing scapels that surgeons use to do this? Any help would be greatly appreciated!

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